TEXAS DEPARTMENT OF CRIMINAL JUSTICE TEXAS CORRECTIONAL OFFICE ON OFFENDERS WITH MEDICAL OR MENTAL IMPAIRMENTS (TCOOMMI) NUMBER: DATE: September 1, 2017 (rev. 7) PROGRAM GUIDELINES AND PROCESSES PAGE: 1 of7 SUPERSEDES: (rev. 6) SUBJECT: CONTINUITY OF CARE-MENTAL HEALTH SERVICES APPLICABILITY: Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI) Continuity of Care (COC) staff and Local Mental Health Authority (LMHA) contracted TCOOMMI program staff. PURPOSE: To provide guidelines regarding the mental health continuity of care services for identified clients releasing from prison or other incarcerated settings or those under community supervision (probation and/or parole), as well as individuals who are pre-adjudicated, charged, or convicted. AUTHORITY: Texas Health and Safety Code, Chapters 614.013, 614.016, 614.017, 614.018 DISCUSSION: Continuity of care is the identification of medical, psychiatric, psychological care or treatment, educational, or rehabilitative service needs and then developing and coordinating a plan for the provision of treatment, care and services between various agencies to offenders with special needs such that services and treatment may continue to be provided at the time of arrest, while charges are pending, during post-adjudication or post-conviction custody or criminal justice supervision, and for pretrial diversion. Continuity of Care (COC) services through TCOOMMI programs are to be provided for up to ninety (90) days for each offender with a severe and persistent mental illness admitted to service with a low clinical need and low criminal justice risk score ( or for eligible offenders awaiting admittance into Intensive Case Management refer to PGP 01.02-Intensive Case Management). PROCEDURES: I. Screening and Referral A. Through review of listings generated by TDCJ Information Technology Division, TDCJ TCOOMMI staff identifies those clients with a diagnosis of a mental illness and issues mental health referrals to the appropriate LMHA contracted program through the use of the TCOOMMI WebApplication (WebApp ). Coordination of the referral occurs upon TCOOMMI staff receiving notice of a scheduled release date and an approved residence plan for a client.
B. TCOOMMI referral records are maintained in the TCOOMMI WebApp. Contracted service providers are required to request and maintain access to the WebApp, as appropriate. Access requests or issues should be emailed to TDCJ TCOOMMI Programs at programstcoommi@tdcj.texas.gov. C. Each contracted service provider is responsible to monitor the TCOOMMI WebApp daily for new referrals. Upon receipt of a referral from TCOOMMI staff in the WebApp, LMHA program staff are responsible to: 1. Schedule an initial service appointment (intake) for the client within ten ( 10) working days of receipt of the referral. 2. Ensure all initial intake appointments with designated COC staff are scheduled to occur no later than fifteen (15) working days after the client's scheduled release. 3. Immediately update the referral in the WebApp to reflect the appointment information. D. Contracted service providers may also receive referrals directly from local probation and parole partners as well as client walk-ins (also known as a local referral). Upon receipt of a local referral, the LMHA program staff are to: 1. Check the WebApp to determine if a referral has not already been issued in the WebApp. If not, create a client record and open a referral in the TCOOMMI WebApp within one (1) working day ofreceipt of the referral. 2. Schedule an initial service appointment (intake) with designated COC staffto occur within five (5) working days ofreferral. 3. Immediately update the WebApp referral with the appointment date and time. 4. Provide notification to the client and the Supervising Officer. E. For juvenile offenders, TDCJ TCOOMMI staff will issue a juvenile mental health referral in the TCOOMMI WebApp to the appropriate LMHA contracted program upon receipt ofa referral from the Texas Juvenile Justice Department (TJJD). Referral notification and a blank Appointment & Outcome Report will be provided to both the appropriate LMHA contracted program and the TDCJ TCOOMMI Compliance Monitor. The LMHA program staff are responsible to monitor the WebApp daily and upon receipt of a referral: 1. Schedule an initial service appointment (intake) within one (1) working day of receipt of the referral. 2. Ensure that the initial service appointment is scheduled to occur with the designated COC staff within ten (10) working days after the tentative release date. 3. Immediately update the TCOOMMI WebApp referral with the appointment date and time. 4. The Appointment & Outcome Report shall be updated with the appointment information and provided via email to TDCJ TCOOMMI Programs at programstcoommi@tdcj.texas.gov, the Case Manager, the Supervising Officer and the appropriate TDCJ TCOOMMI Compliance Monitor. Page 2 of 7
F. Ifthe client presents as needing an immediate evaluation by the psychiatrist ( or similar position) for medication or stabilization purposes, an appointment should be made immediately rather than as outlined in Section IL B below. G. The TDCJ Electronic Medical Records (EMR) system provides instant access to medical and psychiatric records during the client's TDCJ incarceration. All contracted service providers are required to maintain access to the EMR system. Requests for access should be emailed to TDCJ TCOOMMI Programs at programstcoommi@tdcj.texas.gov. The EMR is to be used to review current and previous mental health history, treatment, and medications. A notation is to be made in the file indicating the review of the EMR record or the reason noted if unable to review. 1. In order to avoid interruption access to the EMR system, contracted service providers shall log into the EMR system a minimum of one (1) time every two (2) weeks. 2. Access or printing problems shall immediately be reported to the UTMB Helpdesk at 888-898- 2401, and e-mail notification of the issue shall be sent to TDCJ TCOOMMI Programs at programstcoommi@tdcj. texas. gov. II. Intake A. Within two working (2) days following a client's release, LMHA program staff shall contact the Supervising Officer in order to: 1. Verify the client reported as required, 2. Identify the assigned Supervising Officer, 3. Verify the client's contact information, and 4. Inform the Supervising Officer of service and or treatment appointment information. Additionally, LMHA program staff shall contact the client as a reminder of their intake appointment. B. On the day of the intake appointment, a screening by the designated LMHA program staff will be completed to determine if client meets admission criteria to TCOOMMI Services. If eligible for services and medications are currently prescribed or required, LMHA program staff responsible for intake shall ensure medications continue without inte1tuption. Ifmedication is required, the LMHA program staff shall ensure a follow-up appointment with the doctor is scheduled to occur no more than fifteen (15) working days after release. 1. LMHA Program Staff will complete ANSA if eligible for services during the intake process. C. Within ten (10) days of arrival at TTC, the LMHA shall make contact with offender. 1. Coordinate within fifteen (15) days of a1tival status of offender's placement and expected release date with Legal County of residence (LCOR). Page 3 of 7
2. Coordinate with LCOR release planning and notify offender with appointment information prior to release. 3. Ensure appropriate treatment records are transferred to the LCOR for appropriate post-release services. III. Benefit Coordination A. Not later than ten (10) working days following release, the designated LMHA program staff shall screen all intakes for benefit eligibility and/or reinstatement status. Additionally, during the screening process, the WebApp is to be reviewed to determine if an application was submitted by TDCJ staff prior to release. If appropriate, staff are to complete benefits applications (i.e., Social Security and/or Medicaid). The TDCJ EMR system may be used to provide supporting documentation regarding diagnosis and medications. Completion ofthe application for benefits and or reinstatement must be documented in the client's clinical record. B. LMHA program staff responsible for benefit coordination are to monitor the application for approval or denial status at least once a month and document efforts and results in the client record. In the event of denial of the application, LMHA staff will coordinate any appeal process as necessary. C. For each existing or new prescription for psychotropic medications, the LMHA program staff shall ensure that the appropriate Patient Assistance Program (PAP) application is submitted within ten (10) working days, and document application completion and outcome in the client's clinical record. IV. Program Requirements A. COC services may not exceed ninety (90) days in duration and are intended to serve as a bridge to ensure stable and successful transition from incarceration to community. 1. In the event that the client is determined to require a higher level of service, staff should refer to Section VI. 2. Should the client stabilize successfully in less than ninety (90) days, the client may be closed out and transitioned to other services in accordance with Section VII. 3. All requests for services in excess of ninety (90) days must be authorized, in writing, by designated TCOOMMI staff. B. LMHA program staff are to ensure that the provision of continuity of care includes the following elements: 1. Identification of medical, psychiatric or psychological treatment needs; 2. Develop and coordinate referrals based on identified educational, vocational, housing, transportation and other rehabilitative needs; 3. Determine compliance with medication and treatment objectives; Page 4 of 7
4. Develop and provide a copy of the treatment plan to the client; 5. Provide written monthly updates regarding the client's progress in treatment to include medication compliance to the Supervising Officer; 6. Coordinate and prepare the client for transition to community based services to include transfer to non-tcoommi LMHA programs. C. In the event of a missed appointment, the assigned LMHA program staff are to attempt to make contact with the client by phone no later than the next working day to bring the client back into services. Regardless of the outcome, the LMHA program staff shall notify the Supervising Officer of the missed appointment and, if unable to locate, collaborate with the Supervising Officer to reengage the client to reschedule the appointment. D. After two (2) failed collaborative attempts with the Supervising Officer to engage the client, the LMHA program staff shall staff the case with Supervising Officer for possible case closure and submit an Incident Report in accordance with PGP-01.06. LMHA program staff are to ensure the WebApp is updated to reflect the closure. E. Monthly, the LMHA program staff shall contact both client and Supervising Officer in person, by phone, or by email to discuss ongoing services and/or treatment needs for the client. V. Services While in Custody A. In the event that a client is arrested or detained while in COC services, within twenty-four (24) hours of notification of arrest and/or detention, the LMHA program staff shall forward the most current psychiatric evaluation, medical record and caseworker contact information to the jail and provide an Incident Report, per PGP 0L06 to TCOOMMI Programs, programstcoommi@tdcj. texas. gov. B. Within seventy-two (72) hours of notification of arrest and/or detention, LMHA program staff shall make a face-to-face contact with the client and assess current service needs. C. LMHA program staff shall be responsible to monitor the client's status until such time as the case has been adjudicated or dismissed. Documentation of monthly contact by LMHA program staff with the client's Supervising Officer is required and, upon the client's release from custody, coordination of a referral to TCOOMMI program services. LMHA Program Staff shall be responsible to monitor the client's status for ninety (90) days in custody and if disposition of case is not resolved, COC services will be closed out. D. Requests for COC service provision, to include conducting assessments, may be requested by TCOOMMI staff for those clients not currently admitted in TCOOMMI service programs in order to identify clients not already engaged in services. Page 5 of 7
VI. Case Transfers A. In the event it is determined that a client's case will be assigned to Intensive or Transitional Case Management services, the contract vendor shall close the COC TCOOMMI case and referral and: 1. Inform the Supervising Officer of the newly assigned program Case Manager and provide contact information. 2. Open a new TCOOMMI adult case management referral into the WebApp within one (1) working day of acceptance into case management services and document scheduled appointment information. 3. Document all appropriate client related records. B. Should a client notify of an intent to relocate, the sending LMHA program staff shall contact the appropriate receiving LMHA program staff to determine availability of services. Additionally, the sending LMHA program staff are to notify the Supervising Officer of the requested transfer and the availability of services. C. Upon notification by the Supervising Officer of an approved transfer, the sending LMHA program staff are to complete a county to county referral within the TCOOMMI WebApp to the receiving LMHA program staff within one (1) working day. All appropriate treatment records must be forwarded immediately to the receiving LMHA program to ensure that medications continue without interruption. Note: Should the Supervising Officer confirm that the transfer has been denied, the sending LMHA program staff shall continue current services. D. Within one (1) working day following receipt of a county to county referral, the receiving LMHA program staff are responsible to schedule an intake appointment for the client to occur no later than five (5) working days after receipt of the notice of transfer. The appointment is crucial to ensure that clinically indicated medications are continued. The referral is to be immediately updated in WebApp indicating appointment date and time. E. Once scheduled, the receiving LMHA program staff are to immediately notify the sending LMHA program staff via phone or email of the appointment date and time. The receiving LMHA program staff are responsible to provide both the client and the Supervising Officer notice of the scheduled appointment no later than the next working day. F. The receiving LMHA program staff are responsible to coordinate services with the sending LMHA program staff to ensure not only a smooth transition, but that medications continue without interruption. VII. Case Closures A. All cases must be closed, either successfully or unsuccessfully. A case is considered closed when a client has: Page 6 of 7
1. Absconded: the client is unable to be located and has been declared to have absconded supervision by the Supervising Agency; 2. Been revoked: unsuccessful termination of the client's supervision (probation or parole) by the sentencing authority or the Board of Pardons and Paroles; 3. Refused Services: refusal must be documented in the client record using the Client Refusal form. 4. Not engaged in services: non-compliant with treatment requirements and/or appointments 5. Completed: Has been in services for ninety (90) days or less and has successfully met the treatment goals of the COC program and there is no need for more intensive services as clinically indicated or contractually available through the existing TCOOMMI program. B. An incident report shall be completed in accordance with PGP-01.06 for reasons I - 4 above. All information shall be updated in WebApp, the referral closed and the reason for closure noted. VIII. Medical Continuity of Care Referral A. Should it be determined that a client is unable to self-care or requires linkage with a medical refe1rnl due to a significant or terminal illness (i.e., nursing home placement or hospice care), the LMHA program staff are to utilize the COC Local Referral Form and submit to programstcoommi@tdci.texas.gov with the TCOOMMI compliance monitor and Supervising Officer copied. The document can be found on the TCOOMMI website under "Contracted Vendor Documents" using the below link: http://tdci.state.tx.us/divisions/rid/rid tcoommi contract vendor program.html. B. The COC Local Referral Form for medical continuity of care shall include the client's name and SID number, and have attached the medical records to reflect cmtent medical condition and diagnoses, the client's benefit status and/or source of income, and placement recommendations if applicable. TDCJ TCOOMMI staff shall review the refeital and, if criteria is met, initiate placement and appropriate linkage to care. Page 7 of 7